019200476-8-30-2023-15-AS-YFLS-CWXRST-20231025131715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:40:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/19/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230619150907

FACILITY NAME:	HEART AND SOUL COMMUNITIES II		FACILITY NUMBER:	019200476
ADMINISTRATOR:	GEORGE ANDRE SMITH		FACILITY TYPE:	740
ADDRESS:	2245 SOL STREET		TELEPHONE:	(510) 686-1567
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94578
CAPACITY:	6	CENSUS: 6	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ericka Tillis, Administrator		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility did not follow care plan- special diet was not given
Facility accepted a resident with restricted health condition with out department approval
Facility did not provide documents to responsible party
Facility staff did not seek medical attention in a timely manner for resident in care.

INVESTIGATION FINDINGS:

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On 8/30/23 at 2:00 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Ericka Tillia, Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed the reporting party (RP), the facility administrator (ADM) and reviewed documents received from the RP and the facility. R1 lived at the facility from 2/18/2020 until 10/10/2020. Documents received from the facility show that R1’s guardianship was with Alameda County.

Facility did not follow care plan- Special diet was not given.
Physician’s Report dated 2/19/2020 stated that R1 was on a regular diet with modifications to guard against an adverse reaction due to her colostomy (ie: low fiber).
***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230619150907

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART AND SOUL COMMUNITIES II	FACILITY NUMBER: 019200476
	VISIT DATE: 08/30/2023

NARRATIVE

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***report continues from LIC9099***

Facility accepted a resident with restricted health condition without department approval.

R1 had a colostomy upon admission. Physician’s Report dated 2/19/2020 stated that R1 is capable of caring for her colostomy and only needed help ordering supplies. Per Title 22, Division 6 Chapter 8 Article 11. Health-Related Services and Conditions 87621 this is NOT considered a restricted health condition.

Facility did not provide documents to responsible party.

During R1’s time at the facility her guardianship was with Alameda County. The guardianship was terminated 1 year after R1’s death. The facility is awaiting instructions from the county as to what, if any, documents the facility can share with the RP.

Facility staff did not seek medical attention in a timely manner for resident in care.

Documents received from the RP and the facility show that R1 received routine medical attention in a timely manner. On 10/05/2020 R1 was taken to the emergency department of Sutter Health by facility staff due to concerns that R1’s appetite had decreased and there were several instances of vomiting. R1 was diagnosed with a UTI and discharged back to the facility. Facility staff noticed no improvement in R1’s condition after the round of antibiotics for the UTI was completed. Facility staff brought R1 back to the emergency department on 10/10/2020. R1 was then diagnosed with a bowel obstruction. R1 was admitted to the hospital and later discharged to a SNF on 11/11/2020 where she passed away on 11/18/2020.

This agency has investigated the complaints alleging: facility did not follow care plan- Special diet was not given, facility accepted a resident with restricted health condition without department approval, facility did not provide documents to responsible party and facility staff did not seek medical attention in a timely manner for resident in care.

We have found that the complaints are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this reported provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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